Basic Information
| Provider Information | |||||||||
| NPI: | 1710327986 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANJI | ||||||||
| FirstName: | SRI | ||||||||
| MiddleName: | NIDHI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 NIAGARA FALLS BLVD STE 208 | ||||||||
| Address2: | |||||||||
| City: | NORTH TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141202019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166923302 | ||||||||
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| Practice Location | |||||||||
| Address1: | 116 INTERSTATE PKWY STE 42 | ||||||||
| Address2: | |||||||||
| City: | BRADFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 167011036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147362183 | ||||||||
| FaxNumber: | 8143628385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2013 | ||||||||
| LastUpdateDate: | 03/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD466346 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 103322388 | 05 | PA | MEDICAID | 04817992 | 05 | NY | MEDICAID |